April 13, 20 & 27, 2014
Assiniboine Park – Conservatory
5km races begin at 9:00 am
10km & 15km races begin at 9:05 am
Race packages available for pick up at Pure
Lifestyle - 1129 Empress St. - on the Thursday
and Friday prior to race day.
Registration closes at 8:30 am sharp!
(PLEASE PRINT CLEARLY)
Last Name _________________________ First Name ____________________Male ______ Female ______
Email ____________________________________
Address _____________________________________ City/Town __________________________________
Province _______________________ Postal Code _________________ Phone ________________________
Birthdate __________________________ MRA # ________ Athletics MB # ________ Triathlon MB # ________
Please select your race(s)
All three races – 5km, 10km, 15km
All three races – 5km, 5km, 5km
All three races – 5km, 5km, 5km (youth)
Race # 1 (April 13) – 5km
Race # 2 (April 20) – 5km
Race # 2 (April 20) – 10km
Race # 3 (April 27) – 5km
Race # 3 (April 27) – 15km
Fees Enclosed
1. Race entry fees:
$50 for all three races
$30 for all three races youth (15 + under)
$20 for each individual 5km race
$25 for each individual 10km or 15km race
Add $3 to each registration if not a member of
the Manitoba Runners Association or Athletics
Manitoba or Triathlon Manitoba
$50
__________
$30
__________
$20
__________
$25
__________
MRA, Tr MB or Athletics MB # __________
or $3 One-Day Membership
per event
___________
2. Membership
(for insurance and administration)
TOTAL ENCLOSED
___________
Checks made out to Triathlon Manitoba.
Mail to: Triathlon Manitoba
145 Pacific Ave
Winnipeg, MB
R3B 2Z6
Are you interested in volunteering at this event? Volunteer activities include timing, crowd control, swim monitor, etc. Please see us at check-in on
race day or email Kevin at kevin.freedman@triathlon.mb.ca
* CANCELLATION POLICY – entry fee is totally non-refundable. Registration must be received by the Thursday prior to race day.
* CONFIRMATION – a confirmation e-mail will be sent out to you as soon as your application is received.
CONSENT FOR USE OF PERSONAL INFORMATION
I understand that Triathlon Manitoba, Manitoba Runner’s Association and Athletics Manitoba gather personal information about each of its participants, including
name, address, email, sex, age, and birthdate. This information is used for the purposes of ensuring that each participant competes in the appropriate age group, and
that their name and club will be listed in that age group in the results which are posted on Triathlon Manitoba’s website. The information is also used by Triathlon
Manitoba for annual demographic reporting and to communicate with participants about Triathlon Manitoba, Manitoba Runner’s Association and Athletics Manitoba
programs, events and activities. Triathlon Manitoba Manitoba Runner’s Association and Athletics Manitoba also request medical information and emergency contact
info to use in case of a medical emergency. I have read and understood Triathlon Manitoba’s policy on privacy. I am aware that by giving this consent, I am permitting
personal information about me to be posted to Triathlon Manitoba’s website and publications, which can be viewed by anyone who accesses Triathlon Manitoba’s
website or publications. I understand that I may withdraw consent to the collection, use or disclosure of my personal information at any time by contacting Triathlon
Manitoba.
Participant agreement and waiver
In consideration of the acceptance of this entry in the Pure Lifestyle Race Series I, for myself , my heirs,
executors, administrators and assigns, waive any claims to which I may become entitled for injury or
damage and release Pure Lifestyle and all other organizers, sponsors, representatives, their agents and
employees and any other person or organization assisting in this event, including the Manitoba Runners’
Association, Athletics Manitoba, Triathlon Manitoba, the race directors, the City of Winnipeg, the
Province of Manitoba, and their employees and agents and other participants, sponsors, and volunteers
in the Pure Lifestyle Race Series, from any claims for damages or injury suffered by me as a result of my
participation in this event. I further state that I am in proper physical condition to participate in the
event and I am aware that road running is a potentially dangerous activity and am aware that
participation could, in some circumstances, result in physical injury. I give my permission for the free
use of my name and picture in broadcast, telecast or written account or this event.
Name________________________________________________________
Signature_____________________________________________________
Signature of Parent or Guardian if under 18
_____________________________________________________________
Date_________________________________________________________
Emergency Contact name_______________________________________
Emergency Contact number_____________________________________